McCauley et al. BMC Public Health 2013, 13:1116http://www.biomedcentral.com/1471-2458/13/1116
RESEARCH ARTICLE Open Access
The H1N1 pandemic: media frames, stigmatizationand copingMichael McCauley1*, Sara Minsky2 and Kasisomayajula Viswanath2
Abstract
Background: Throughout history, people have soothed their fear of disease outbreaks by searching for someone toblame. Such was the case with the April 2009 H1N1 flu outbreak. Mexicans and other Latinos living in the US werequickly stigmatized by non-Latinos as carriers of the virus, partly because of news reports on the outbreak’s allegedorigin in Mexican pig farms.
Methods: In this exploratory study we examined the psychological processes of cue convergence and associativepriming, through which many people likely conflated news of the H1N1 outbreak with pre-existing cognitive scriptsthat blamed Latino immigrants for a variety of social problems. We also used a transactional model of stress andcoping to analyze the transcripts from five focus groups, in order to examine the ways in which a diverse collectionof New England residents appraised the threat of H1N1, processed information about stereotypes and stigmas, anddevised personal strategies to cope with these stressors.
Results: Twelve themes emerged in the final wave of coding, with most of them appearing at distinctive points inthe stress and coping trajectories of focus group participants. Primary and secondary appraisals were mostly stressfulor negative, with participants born in the USA reporting more stressful responses than those who were not. Latinoparticipants reported no stressful primary appraisals, but spoke much more often than Whites or Non-HispanicBlacks about negative secondary appraisals. When interactions between participants dealt with stigmas regardingLatinos and H1N1, Latinos in our focus groups reported using far more negative coping strategies than Whites orNon-Hispanic Blacks. When discussions did not focus on stereotypes or stigmas, Latino participants spoke muchmore often about positive coping strategies compared to members of these same groups.
Conclusions: Participants in all five focus groups went through a similar process of stress and coping in responseto the threat of H1N1, though individual responses varied by race and ethnicity. Stigmatization has often beencommon during pandemics, and public health and emergency preparedness practitioners can help to mitigate itsimpacts by developing interventions to address the social stressors that occur during outbreaks in highly-localizedgeographic regions.
Keywords: H1N1, Communication, Media frames, Latinos, Stigmatization, Stress and coping
Background
I think that fear is not good for things. What feardoes… is it causes one to make mistakes.— Latino focus group participant
Infectious diseases have shaped the course of human his-tory, resulting in more deaths than any other pathological
* Correspondence: [email protected] of Medicine, Medical College of Wisconsin, Milwaukee,WI 53226, USAFull list of author information is available at the end of the article
cause [1]. And when diseases are thought to be lethal,people who perceive a great risk of infection sometimescope with their fears by blaming new disease outbreakson someone, or some group of people, who live outsideof their own social sphere. In many societies, peoplewhose national, ethnic or religious backgrounds differfrom those of the majority group have historically beenaccused of spreading germs [2,3]. Such lay theories ofdisease transmission, often based on inaccurate risk per-ceptions and pre-existing social prejudices, serve twoimmediate functions: they temporarily soothe the anxiety
ral Ltd. This is an Open Access article distributed under the terms of the Creativeommons.org/licenses/by/2.0), which permits unrestricted use, distribution, andiginal work is properly cited. The Creative Commons Public Domain Dedicationain/zero/1.0/) applies to the data made available in this article, unless otherwise
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felt by the accusers, while also stigmatizing those who areblamed [4,5]. This same sort of disease narrative capturedthe public imagination in April 2009 when A(H1N1), anovel strain of human influenza, appeared in Mexicoand spread rapidly around the world. Some of the earliestcases were discovered near Mexican pig farms (hence,the “swine flu” nickname) and Latinoa immigrants fromthat country, and others, were often pronounced guiltyby association. Soon, Mexican nationals and the productsthey produced were shunned across the globe; in theUnited States, some talk show hosts portrayed Mexicanimmigrants as disease vectors who threatened the healthand security of other citizens [3,6]. This was especiallyunfortunate since disadvantaged groups in any society,including racial/ethnic minorities, suffer disproportion-ately during disease outbreaks [7,8]. US Latinos havehigh rates of chronic health conditions such as diabetes,obesity and asthma, which put them at greater risk forgetting the flu – and for developing complications oncethey have it [9,10]. Compared to other social groups,Latinos have less access to healthcare, wait longer toseek medical help, and have fewer opportunities to ob-tain sick leave – or to utilize this benefit when theyhave it [11,12]. If the lessons of history hold true, theconsequences of H1N1 stigmatization may deepen thesense of social marginality that many US Latinos alreadyfeel [13,14].In order to mitigate the negative consequences of
stigmatization during pandemic outbreaks, public healthofficials must learn to recognize the dynamics that under-lie this process, with special emphasis on protecting mem-bers of disadvantaged population groups [7,15]. Hence, itis important to understand how people’s fear of contagionduring the 2009 H1N1 outbreak became associated witha broader set of fears about Latinos and the roles theyplay in American society. An emerging body of litera-ture points to the competing goals of three interestedstakeholder groups: media organizations and journalists;the public health officials that journalists relied upon for
Figure 1 The role of framing and priming in the construction of med
information about H1N1; and citizens who feared thespread of this disease and struggled to make sense of it.Figure 1 suggests one way in which competing framesabout pandemic illness and US Latinos – including thesocial consequences of Latino immigration – collidedand combined during the spring and summer of 2009.Through the process of frame-setting, the news media
actively develop the frames of reference that readers orviewers use to understand public events [16,17]. Yet theinterpretations that journalists convey in their storiesare often rooted in factors that lie beyond the simplereporting of facts. They are complex products of organi-zational constraints and professional judgments whichare, in turn, influenced by the frame-building efforts ofexternal sources [16,17] – including, in the case of H1N1,the US Centers for Disease Control and Prevention(CDC) and the World Health Organization (WHO).Among its many functions, WHO is responsible formonitoring disease outbreaks and warning the publicwhen they cross borders and become international pan-demics [18]. When cueing the CDC (and, hence, the USnews media) about the threat of H1N1 in April 2009,WHO relied on a communication campaign that hadactually been created to address a lethal outbreak ofavian influenza; hence the ready analogies that someofficials made to the deadly Spanish Flu pandemic of1918 [19]. This strategy was a contributing factor in thesensational media coverage of H1N1 that developed inthe US, a circumstance that challenged the ability ofdisease experts to communicate about the virus in acalm and dispassionate manner [20-22]. This campaignwould ultimately cause a great deal of confusion, as theoverall impact of the H1N1 in the US was significantlymilder than public health officials first feared [23-26].Nonetheless, nearly half of the respondents in an April
2009 national survey [27] were concerned that they orsomeone in their family might get sick. 59 percent saidthey had begun to wash hands or use hand sanitizer morefrequently, and 25 percent said they were avoiding malls,
ia cues about H1N1 and Latinos.
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sporting events or public transportation. And since mediareports pegged the origin of H1N1 to Mexican pig farms,heavy coverage of the outbreak likely helped to activate abroader set of fears which held that Mexicans and otherLatinos might actually be spreading the disease. Indeed,20 percent of respondents to the same survey said theywould avoid people who they thought may have recentlytravelled to Mexico; another 17 percent said they wouldavoid Mexican restaurants and stores [27].In exploring these processes, we do not suggest that
certain groups of fearful US citizens made consciousdecisions to vent their frustrations on Latinos. Insteadwe posit a subtler form of bias that medical historianHoward Markel describes as a “fear of people we donot know or who look different”. In an interview withmsnbc.com, Markel – a senior CDC consultant on pan-demic preparedness – said that when “you take the fearof the unknown that already exists and then combinethat with a real or perceived threat that is contagiousdisease… it’s explosive” [3]. Following this train of logic,we can begin to understand how the fear of contagioncan become associated in an anxious person’s mindwith a generalized fear of minorities [28]. Social psy-chologists suggest that this sort of associational trajec-tory develops in a part of the human brain that storesthe network of interconnected cognitions which com-prise long-term memory [29]. Given a vast array of pos-sible connections, any singular concept that is encodedinto memory (e.g., anxiety about flu outbreaks) may be-come associated with other constructs (e.g., the urge toassign causes and cures). And every time these conceptsare activated in tandem, the connections between eachmember of the “concept set” become stronger. Regard-ing our study, the presence of threatening linguistic“cues” in news stories about pandemic illness may trig-ger or activate other constructs that are stored in longterm memory (e.g., fears that immigrants are diseasevectors). This process of cue convergence, and the result-ing activation of associated constructs (associative priming)[29], represents one pathway through which a person’smemories about flu pandemics may combine with his-torical or latent racial/ethnic fears to make incidentalcontact with Latinos seem like a dangerous proposition(Figure 1).To be clear, these processes do not imply that the
news media are solely or even mostly to blame, as high-profile talk show hosts (who do not follow the profes-sional conventions of journalists) arguably took a moreactive role in developing and propagating certain laytheories about the pandemic. Some dubbed it the “fajitaflu” and took the growing number of cases as evidencethat the uncontrolled flow of illegal aliens across thesouthern US border posed a clear and present danger;others suggested that the H1N1 outbreak could be part
of a larger conspiracy in which terrorists targeting theUS would infect Mexican immigrants and turn them intowalking, talking weapons of germ warfare [3,5,6,30]. Giventhe public’s fear of the unknown, and the ways in whichthe media stoked this fear with a variety of associativecues, many US Latinos were likely stigmatized and stereo-typed during the pandemic. In general terms, stereotypesare cognitive shortcuts that help a person to developquick, superficial “readings” of people from other socialgroups [15]. Whether conscious or implicit, stereotypesare a frequent by-product of stigmatization – the “marking”of certain individuals or groups according to a socially-conferred judgment that they are somehow tainted, orless than, members of the majority population group[31]. Stigmatization stems from the fears that peopleoften face during times of uncertainty, including publichealth emergencies like the H1N1 pandemic [30-33].Apart from disparaging media portrayals of Latinos, aseries of interviews with US public health advocates in2009 showed that Latino seasonal farm workers oftenfelt stigmatized or shunned by other people in the com-munities where they lived or worked [5]. Governmentofficials, Latino advocacy organizations and public healthgroups moved to denounce these occurrences [34,35],yet it is likely that stigmatization exacted a toll. Peoplewho are subjected to social avoidance or rejection ofteninternalize the stigma they experience, a process thatleads to heightened psychological stress and anxiety –and, in some cases, to an increased susceptibility toillness [15,36,37]. It is also important to note that theprocess of stigmatization may negatively impact thepsychological and physiological health of people whohold derogatory or prejudicial beliefs about membersof another social group [38-40].How did US residents deal with the stressful circum-
stances of the 2009 pandemic? One plausible frameworkfor understanding this is Lazarus and Folkman’s transac-tional model of stress and coping [41]. We have adaptedthis model (Figure 2) in a way that describes a processthat both stigmatizers and the stigmatized go throughwhen confronted with distressing social situations.In this model, stressful experiences are conceptualized
as person-environment transactions which depend, firstof all, on the impact of an external stressor (e.g., mediacoverage of H1N1). Research suggests that we humansare “spring-loaded” to evaluate our informational envir-onment, and that our initial evaluation of stressors mayhappen subcortically, prior to any conscious awarenessor emotion [42,43]. This orienting response can be sud-den and unintentional; and since it functions as a psy-chological early warning system, it often assigns priorityto stimuli that are threatening in nature [43]. From thestandpoint of those who stigmatize, it is thus possiblethat certain media cues about pandemics can quickly
Figure 2 A stress and coping framework for the processing of H1N1-related media discourse.
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activate elements of historical or latent stereotypes aboutLatinos that are stored in long-term memory – withoutany sort of conscious intent or present-day belief on thepart of a person having this response [44,45]. Thesesame media cues may activate a different sense of appre-hension on the part of Latinos who have often, and invarious ways, felt the burden of prejudice and discrimin-ation during times of widespread social unease, includ-ing the early stages of pandemics.The next step in our model is primary appraisal, in
which individuals evaluate the demands of the potentialstressor to determine whether it is important to theirown well-being or the welfare of people they hold dear.When people judge the stimulus at hand to be irrelevantor benign, they spare themselves from psychological stress[41,42,45]. But when a threatening event seems likely toproduce negative consequences, their agitated responsehastens a secondary appraisal. Here, people evaluatethe resources they might use to mitigate the threat.During this process, individuals may evaluate whethertheir available psychological resources (e.g., self-esteem,optimism, self-control), personal resources (e.g., income,
education, occupational status) and social resources (e.g.,family resilience, social support, ingroup identificationand evaluation) will help them to stay resilient in timesof danger [33,46]. During secondary appraisal people ask,in effect, whether they have what it takes to manage thechallenges of a threatening circumstance [41-43,45-47](Figure 2).When individuals go through primary and secondary
appraisal, yet continue to experience the stressor in athreatening manner (e.g., because of a steady stream ofH1N1 news) they experience psychological stress andmust find ways to respond. Our model of stress andcoping acknowledges the distinction between involuntaryresponses to stress and voluntary coping responses. Regard-ing the first category, people may have involuntary emo-tional, behavioral, psychological and cognitive responsesto stress that do not serve to regulate stressful experi-ences, including physiological and emotional arousal,rumination and intrusive thoughts, and impulsive actions.Whether conscious or unconscious, these responses “areexperienced as being largely outside of the person’s con-trol” [48]. Coping, on the other hand, denotes “conscious
Table 1 Demographic characteristics of cities/towns wherefocus groups were held*
City A** City B City C City D
Population 600, 980 7,380 72,043 7,827
Race/Ethnicity
White 56% 85% 49% 98%
Black 24% 11% 5% 0.4%
Hispanic 16% 7% 60% 1.2%
Education
≥ HS 84% 82% 58% 84%
≥ College 27% 31% 10% 17%
Income
Median HH Income $48,729 $60,752 $27,983 $49,310
Families < Poverty Level 17% 4% 21% 4.5%
Individuals < Poverty Level 21% 4% 24% 6.8%*Figures are based on 2000 and 2005-2007 US Census data.**Two of the five focus groups were held in City A.
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volitional efforts to regulate emotion, thought, behavior,physiology and the environment in response to stressfulevents or circumstances” [48,49].If the resources a person can draw upon seem suffi-
cient for dealing with a stressor, that person may selecta positive-engaged coping strategyb such as problem-solving, finding a good balance between emotionalexpression and emotional regulation, or cognitiverestructuring – a strategy discussed more thoroughly inour Results section. To give an example of a positive-engaged problem-solving strategy, a White person whois troubled by the prospect of Mexico’s role in the H1N1outbreak – but confident in his/her ability to cope –may reduce stress by learning all that he/she can aboutthe virus through respectful conversations with Latinoacquaintances. But if news coverage of the outbreakstimulates a threatening response, and the individualdoes not feel up to the challenge, that person maychoose a negative-disengaged coping strategy such asavoiding or denying the problem, or antagonizing peoplewho seem threatening (e.g., Latino restaurateurs or travel-lers who have just returned from Mexico). Members oftraditionally stigmatized groups may also employ thewhole range of voluntary and involuntary responses tostress. Of special concern to public health practitioners,people who feel stigmatized during pandemic outbreaksmay turn inward or isolate themselves from social con-tact, making it more difficult for them to receive appro-priate medical care [11,12]. Finally, we suggest – byinference, not empirical evidence – that the strategy aperson chooses for coping with a public health crisiswill ultimately have an impact on disease susceptibilityand health outcomes (Figure 2).In this study, we will demonstrate the ways in which
public health officials can recognize and understandthe potentially harmful dynamics that underlie thestigmatization process during pandemic outbreaks. Spe-cifically, we will utilize the model of stress and copingoutlined above to inform an exploratory analysis of fivefocus group sessions conducted in New England duringthe H1N1 outbreak of 2009. By revisiting these tran-scripts with an eye toward the structural elements ofour model, we will highlight the primary and secondaryappraisals of focus group participants following theirexposure to media reports about the pandemic. We willshow, in various ways, how the appraisals these peoplemade are linked to the involuntary and voluntary re-sponses that resulted. And we will show how recentresearch on the psychological makeup of stigmatizersand the stigmatized can offer guidance on the designof anti-stigma interventions whose effects may be longer-lasting than traditional education-based interventions.This study makes no claim to generalizability in thebroadest social-scientific sense. Instead, we follow Sim’s
conception of theoretical generalizability [50], with theintention that our results will produce theoreticallyuseful insights for others who may conduct future studiesabout stress and coping during public health emergencies.
MethodsParticipants and settingOur focus groups were originally conducted as formativeresearch in support of a larger study of public healthemergency preparedness (PHEP) communications. Thisproject, which included a public opinion survey, soughtto better understand the information sources peopleused when developing emergency preparedness plans, thelevel of trust they had for various information sources,and the knowledge and perceptions they held with respectto the 2009 H1N1 outbreak.c Participants were recruitedthrough newspaper advertisements and flyers, and fromthe rosters of other projects undertaken by a major re-search institution in New England. The goal for each focusgroup was to recruit 8-10 participants, ages 25 and older,from diverse ethnic, racial and socioeconomic position(SEP) groups in the New England locations described inTable 1. A total of 46 participants were recruited for fivefocus groups (two in City A), with an even representationof both rural and urban residents.A large proportion of participants came from low-SEP
and underserved population groups (See Table 2) and aSpanish-language focus group was conducted in City C,where the Latino population comprised nearly 60 percentof the city’s overall population. (Table 1) Participantsranged from 26 to 72 years of age and had educationallevels from 4th grade to Bachelor’s degree (Table 2).
Table 2 Participant characteristics, by focus groups
HH < poverty level 8 1 2 5 35%*Two of the five focus groups were held in City A.
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Focus groupsThe focus groups, approximately 90 minutes in length,were held at locations that were easily accessible to par-ticipants. Following standard protocol, participants werewelcomed to the discussion by investigators, informedabout the purpose of the research and given a set ofground rules, including the expectation that they respectand listen to each other. Following a briefing on record-ing procedures, each focus group was audio-taped andtranscribed. Most of our focus groups (Cities A, B & D)were conducted in English by a cultural anthropologistwith extensive experience in facilitating focus groups.The group in City C was conducted by a Spanish-speakingmoderator who also has extensive experience in focusgroup research. (See Additional file 1 for a copy of ourfocus group script).
AnalysisTranscripts were analyzed according to a standard com-prehensive qualitative analysis method, which involved athree stage coding process. In the structural coding phase,the principal analyst coded textual elements in each tran-script that corresponded with the ways in which ourrespondents first encountered H1N1-related stressors,appraised the attendant level of threat, and developedstrategies to try and mitigate the threat. This portionof the analysis was enhanced by the use of NVivo (QSRInternational), a state-of-the-art ethnographic data man-agement software program. The second wave of analysis
followed the immersion/crystallization method [51], aprocess that involves immersing deeply in key portionsof the coded data – then backing away from it at regularintervals for the purpose of reflection and second-leveltheme formation. When this wave of coding was complete,revised output reports from NVivo were generated andscrutinized. All authors reviewed the results of thesecoding processes and contributed to the comprehensivesummary of qualitative findings detailed in the next section.
Ethics and consentThe Institutional Review Board at the Harvard Schoolof Public Health determined that the focus groups con-ducted for the present study were exempt from anyregulations pertaining to the conduct of research onhuman subjects. All focus group participants completedappropriate consent forms and each was paid an incentivefor his or her participation.
ResultsTwelve themes emerged in the final wave of coding, withmost of them appearing at distinctive points in the stressand coping trajectories of our focus group participants(Table 3).
Orienting responses and primary appraisals“What are we in for?”The initial orienting responses that people have to astimulus are “rapid and automatic” – quick reflexes that
Table 3 Summary of study themes
Themes Examples
Primary appraisals
Stressful What are we in for? “I don’t know what I would do if anyone in my family got sick”
“Even the young and normally healthy people are getting sick”
Secondary appraisals
Positive (“meet the challenge”) Plans and Precautions “Taking precautions against viruses… is just part of my routine”
Neutral It’s not so bad “I never get the flu, so I really wasn’t concerned”
Negative (“threatening”) Nobody Knows” “I don’t think anyone has a full understanding of this flu”
It’s In The Air “H1N1 is in the air. If you’re exposed to it, you will get it”
Isolation “We’re isolated in my neighborhood/We don’t know, or help, each other”
Coping strategies
No Stereotype Discussed
Positive-engaged Too Much News, Too Many Germs “Now, I’m more alert as to how you can catch germs”
Negative-Passive Who Can I Trust? “I think the government is just tryin’ to get people worked up”
Stereotype Discussed
Positive-engaged Protection, not Isolation “Take precautions, but live your life… and care for people in need”
Raising Consciousness “Widespread fear has economic consequences - especially for Latinos”
Negative-Passive Subtle Stigma “Is our lifestyle ’cleaner’ than the lifestyle in Mexico?”
We’ve Heard This Story Before “Americans are not very sensitive to minorities during disease outbreaks”
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“assign an initial processing priority through the alloca-tion of attentional resources” [43]. Our focus group datado not contain direct evidence of this cognitive earlywarning system. But they do contain evidence of pri-mary appraisals, the initial analyses in which peopledecide whether the stimulus at hand (i.e., news aboutthe flu outbreak) is threatening to themselves or some-one they care for. In our study, most of the primaryappraisals we could discern were stressful in nature.Take the comments of these two participants, forexample – first a White woman from a rural community,then a Black woman from a major city.
I remember the first outbreak of the swine flu, andI’m like, “Oh, crap!” When they’re talking about itcrossing the borders and all of that… I mean I, too,am very concerned.
You know, I, I just panicked, you know, because I don’tknow what I would do if… you know, anybody in myfamily was sick with the swine flu.
Reactions like these are hardly surprising, as primaryappraisals are often based on information that is seem-ingly dangerous – and incomplete. And since theseappraisals are often suffused with negative emotion, it
is also no surprise that our participants would focuson news about severe cases and rapid propagation.d
F: ‘Cause usually when you get an outbreak orsomething like the flu, or something that kills people,they always say it’s little babies or older people… Butthen we’re seeing like healthy people, you know, peoplewho are in, um…
M: …in the best of shape.
F: Yeah, and… who were, you know, younger. And itwas still… they were still gettin’ very sick from it. Sothat was kind of scary, because it was, like, acrossthe board.
Secondary appraisals“Plans and precautions”Secondary appraisal occurs when anxious individuals evalu-ate the availability and effectiveness of the resources theycan muster in dealing with the perceived threat. Someparticipants from City B, which had the highest meanlevels of education and income in our sample, felt rea-sonably safe since health officials, public safety officersand other civil servants had already made effective pub-lic communications about their plans for containing aflu outbreak. At least some participants in all of our
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study locations felt they could stay reasonably safe bysimply following the precautions mentioned by journal-ists, healthcare providers and other sources.One woman from City A, a large urban area, noted
that her occupation prepared her quite well for the taskof warding off viruses.
And generally, it’s part of my routine, because I workwith kids. So, everything that I touch… as soon as Imove, I gotta’ wash it. So it’s like, when that outbreakcame out? It was like nothing new. We were alwaysdoing that.
“It’s not so bad”Some participants made neutral appraisals of H1N1, tak-ing note of the pandemic but concluding that no actionwas necessary. Three people from City A reasoned thatwhile other people were vulnerable to H1N1, they wouldprobably be OK. And a woman from City D, a small,rural community, was among several participants whoexpressed only minimal concern, saying the outbreakwas not as bad as other people might think.
Since I never have the flu, you know, I really wasn’tconcerned. Then I listened a little more… ‘cause Ifigured all the amount of people that have had it, andthe few people that have died from it… it’s all relative.And I’m really not that concerned.
“Nobody knows”However, most people in our focus groups made nega-tive secondary appraisals, judging that their coping re-sources might not be enough to keep them healthy. InCity A, where income and education levels are compara-tively low, participants in one focus group had troublecomprehending all the fast-breaking details about H1N1.Some members of this group blamed the situation onhealth experts and news reporters who failed, in theirview, to provide enough useful information.
F1: I don’t think we got the full understandin’ of theswine flu. And people can’t get over it.
F2: I don’t think they have a vaccine for it.
M1: I don’t think they have enough.
F3: Yeah, they prompt us sayin’ that they did. Butthey… they really don’t. They haven’t figured it outhow to make it yet.
And a man from the other focus group in City A saidthe flu outbreak shook his sense of confidence that
biomedical scientists even know how to protect the pub-lic from harm.
You know, we have kind of the top scientists andeverything in the world… It amazes me that we can doso much for other countries and come up with somany different things for them. But somethin’ hit athome, we are completely baffled and lost with it.
“It’s in the air”Some focus group participants from City C – all Latinosof Dominican descent – also felt the H1N1 outbreakmight overwhelm their ability to cope. On the whole,people in this group were quite knowledgeable about theways in which flu is transmitted, noting that viruses aresimply “in the air” and that there is little that a personcan do to hide from them.
“Isolation”Even more important, people from City C were afraidthat in responding to the threat of H1N1, healthcareworkers and government officials would actually deepenthe sense of physical and social isolation they alreadyfelt. As members of an immigrant culture that is defined,in part, by the fear of arbitrary deportation, these peoplewere naturally wary about the impacts of medical quar-antine. In particular, some of the women in this groupfeared the disease could wreak havoc in their tightly-knitcommunity – if health officials required, for example,that they care for infected children at home.And some older members of this group were painfully
aware that social support – a key factor in resilient re-sponses to pandemic disease – was not available to themin the United States in the same way they encounteredit back home.
M: If a method was available – a neighborhood, a clubwhere people could get reunited, and get to know eachother better, and talk – then you would know the peoplein your neighborhood… share together, you understandme? But each person lives isolated one from the other intheir rooms. You enter your house and lock yourself, andno one knows each other most of the time.
F: Because we are afraid of each other.
M: That is what is happening, that sometimes thereisn’t friendship. There are no friends or anythingbecause we don’t believe each other.
Coping strategies and other responses to stress“Too much news… too many germs”When people continue to perceive environmental stressorsas threatening despite their available stores of mitigating
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resources, they search for ways to respond – to managethe negative emotions they experience or, perhaps, toalter the stressful circumstances that cause these emo-tions in the first place. Some focus group respondentsseemed unable to find enough resources to calmlyaddress the challenges of H1N1, and coped by simplyavoiding news coverage of the pandemic. And somecoped with the glut of H1N1 news in ways that suggesteda pre-existing set of compulsive behaviors designed tokeep themselves, and their families, germ free – perhaps,as a means of diverting their attention from the constantbarrage of H1N1 news. For example, a group of womenin City D developed an impromptu checklist of itemsthat should always be cleansed with antibacterial lotionor wipes, including telephones, shopping carts, money,pens used in public – and, in some cases, visitors toone’s home.
“Who can I trust?”Some anxious respondents became overwhelmed by thesheer amount of information available about H1N1, andby the fact that news coverage of the outbreak containeda fair amount of conflicting information. In some casespeople seemingly drifted into a state of denial about thesignificance of an H1N1 pandemic. According to thiselderly White woman from City D, too many peoplewere making a fuss about the pandemic – “saying thisand that” until it all seemed like so much noise.
And I think the… the government is puttin’… puttin’things into peoples’ mind… [Along] with a lot of otherthings, I think the government is just tryin’ to getpeople worked up.
An African-American woman from City A, who listenedmore carefully to the news, complained about mixed mes-sages from the highest echelon of federal government.
Other people were sayin’, “Oh, it’s safe. It’s … I’m notgonna’ worry about it. And then Joe Biden comes onand he’s sayin’ “I’m not gettin’ on a… if it was myfamily member, I’m not… I wouldn’t put ‘em on aplane, or train or anything.” So then you’re like, “Well,who am I supposed to believe?”
At one level, these comments provide evidence of an in-voluntary sort of rumination about the ultimate meaningof conflicting news reports. At another level, they suggesta fraying of trust for some focus group participants re-garding the ability of government officials to adequatelyprotect US residents during pandemic flu outbreaks – or,at very least, to communicate with them in a manner thatis clear, concise, and sufficiently useful.
“Subtle stigma”Many people in our groups were skeptical about trav-eling to Mexico anytime soon. In most cases they sim-ply shared an understandable impulse to stay awayfrom the epicenter of a threatening disease. But thetone of the discussion shifted, at times, in ways thatsuggested an aversive response – a subtle form ofstereotyping with respect to Latinos, including thepropagation of lay theories about differing lifestyles inthe US and Mexico. One interesting thread developedin the focus group that met in City B (small town,high SES, mostly White) when an anxious woman grilledanother participant – a local health official – about theseverity of the 2009 pandemic.
F: The mass amounts of people dying. It’s, it goes backto my whole thing of… why is it that this country[USA] didn’t have the amount of deaths that othercountries did? Are we doing something different? Arewe more, um… do we have better resources throughthe CDC or something…
M: We have… we have better resources.
F: …to do that? But… how could we use that to beable to, to… to keep that from being as bad as, per se,Mexico the NEXT time it comes around… if it does?
At another point in the discussion, this same womanconfessed a sudden aversion to continuing with routinefamily outings at restaurants and other public facilitiesin a large city, located about an hour’s drive away.
I kind of looked at it and said, “Well you knowsomethin’? That, that little evening out doesn’t have tohappen this month or next month. We can push it offand wait… till later.”
Taken as a whole, these comments provide evidence ofthe speaker’s desire to avoid uncomfortable feelingsabout the threat of contamination – first by favorablycomparing her own social reference group (i.e., “WhiteAmerica”) to that of people who live near Mexican pigfarms, and then by physically avoiding places she deemedto be risky. The lone Latino participant in City B listenedattentively to these comments and offered a bit of “push-back” regarding the economic impact of such behavioron restaurateurs and other Latino businessmen.
“We’ve heard this story before”When studying stigmatization and other impacts of so-cial stratification, it is important to understand the waysin which historical context may shape a person’s views of
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present-day experiences [52]. For instance, several Latinoparticipants in City C spun a fascinating thread of discus-sion when asked about their information-seeking habitsduring the 2009 pandemic; indeed it was the first of twoinstances in which Latinos showed evidence of cognitiverestructuring [48,49]. In the example that follows, this sortof restructuring helped people to redefine an unpleasantsituation in a culturally-relevant manner that, in theend, also helped to mitigate stress. One man said he hadlearned on the Internet of a 1982 outbreak of Africanswine fever (ASF) in his native land. ASF is extremely lethalfor pigs and US agricultural officials – fearful the diseasewould spread, and then decimate the US pork industry –worked with Dominican and Haitian officials to exter-minate hundreds of thousands of infected native pigs[53,54]. This fact did not escape the attention of otherfocus group members.
M1: All of the pigs. It finished off everything, and theyhad to bring in a new race. And that is how all of thepigs, the tumaron and the black one…
F1: And the black one.
M1: It finished everything and a new type of white pigcame in.
F1: Americans.
F2: Another race.
M1: American ones, another race. So say… well, if thistime we can’t finish all of the people… [Everyone laughs]
At this point, a female participant said her mother,formerly a pig farmer, believed the “swine flu” of 2009was not new – that it was, in fact, the very same diseasethat ravaged native Dominican pigs in the late 1970sand early 1980s. Though this argument is literally un-true, it offers an important fulcrum for analysis. ASF isnot the same as H1N1, most notably because the ASFvirus has no direct impact on humans [54]. Still, it is un-deniable that some Dominican and Haitian pig farmerslost a significant portion of their livelihood because of adisease outbreak in which US officials helped to killthousands of native pigs. Thus, focus group participantsin City C used memories of the ASF outbreak as a cog-nitive shortcut for understanding the social hazards theymight face during an H1N1 outbreak in the United States.By intimating that “we (Latinos) have seen this (American)flu before”, they were able to bring a sense of sharedmeaning to the task of coping with a threatening circum-stance whose solution seemed to lie beyond their control.
“Protect yourself but use common sense”To be sure, our focus group participants – especially thosewho lived in low SEP, urban settings – also engaged inpositive coping strategies, using a blend of problem-solving and appropriate emotional expression. Severalpeople showed a deep empathic streak upon hearing ini-tial reports of the flu pandemic, including an African-American man from City A who wondered if internationalhealth agencies would be able to supply Mexican citizenswith face masks that did a better job of filtering viruses.Closer to home, some participants noted awkward momentsat church, where nervous preachers advised against friendlycontact – and were promptly ignored. Latinos from City Cspoke about their efforts to balance flu prevention measureswith the practical demands of social life. And two womenfrom City A launched a spirited bit of push-back against theprevailing US culture of germ phobia, noting that childrenwho grow up “playing in the dirt” have healthier immunesystems than those who are raised in a sanitized “bubble”.
“Love God, then call 911”One brief, but fascinating exchange provides a glimpseof a potentially resilient strategy, a bit of cognitive re-structuring that Latinos in City C apparently use whencoping with public health emergencies. It began whenthe moderator asked “How are you prepared?”
M1: Well because I always think that there is a specialprotection over me that comes from [God] the Father.
F1: That’s true.
F2: Amen.
M1: I’ll always feel safe. Yes.
Moderator: And the rest of you? Do you know what todo in case of an emergency?
F1: Love God.
F2: Love God and then call 911.
F1: God can make a miracle right there.
This passage offers a glimpse of a Latino-Americancoping style that Florez et al [55] refer to as destino – adeep sense of conviction that one can overcome anyobstacle in life by combining the grace of God’s blessingswith a healthy dose of self-efficacy and hard work. Thedestino narrative, which surfaced frequently in the CityC focus group, stands in contrast to the commonly-heldview that US Latinos approach a variety of intractablehealth problems with a fatalistic attitude. Latinos in our
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focus groups showed no signs that they would “give up”when faced with the challenges of H1N1, or with the at-tendant difficulties of stigmatization. Armed with thebelief that “God helps those who help themselves”, theyspoke of many ways in which their abiding faith in ahigher power helped them to meet and surmount manyof life’s challenges. In this manner, they were able to re-duce the impact of the emotional arousal that followedheavy media coverage of the flu pandemic.
“Raising consciousness”Finally, several participants responded positively, andadaptively, in discussions that focused directly on theflu-related discrimination that Latinos sometimes facedin 2009. The best example comes from City B, where the“anxious participant” described above joined a highlycharged interaction between two other members – andgot more than she bargained for in return. It began withan observation by the lone Latino member of this other-wise White group that the media were unjustly hatching“theories” that blamed the spread of H1N1 on peopleborn south of the US border.
M1: Blame it… blame it on Mexico, not us.
F1: Right. That’s right. And I think that’s…
F2: We’re blamed enough. We don’t need any more!(Chuckles)
F1: With the number of people that, that I had aconversation with, you know, the general thoughtwas: “Oh, yeah, it came from Mexico, and they justdon’t have the regulations like we have on meat andfood.” And, you know, “We’re on top of things here inthe United States. It can’t possibly touch us.” Andthat’s where the disillusioning piece comes into play.And if that helps you to sleep at night… well, I don’tknow. I’m not so sure that that’s a good, right wayto handle that.
In effect, the defensive comments of the anxiouswoman – which appear above in bold-faced type – trig-gered a quick response by another White woman in thegroup, who spoke about the unforeseen consequencesH1N1 stigmatization in a manner that was emotionallybalanced and appropriate. Later, the Latino business-man who started this conversation highlighted the pos-sible impacts of subtle or implicit stereotyping.
I mean, right here we have an example of [arestaurateur who] lost revenue because a trip that [F2]normally takes into [City A] to do something, she chosenot to do. And, and that’s happening… because people
are concerned about what happens at the restaurant.Yeah, we’re talking health here… but definitely, animpact on the economy.
These exchanges in City B are significant because ofthe unexpected opportunity they offered participantsto actively confront and contest certain implicit racial/ethnic biases that link Latinos to the spread of H1N1.This narrative took shape based on the comments ofthe group’s only Latino member, a well-educated andwell-traveled businessman. Safe within the confines of thefocus group setting, he had an opportunity to voice hisconcerns calmly and effectively – a discursive avenue thatis often unavailable to members of racial/ethnic minor-ity groups when discussing these matters in public.
DiscussionOur study has attempted to explain the ways in whichtwo separate strands of concern about disease, and the“exotic others” who threaten to spread it, came togetherin the spring of 2009 to make it seem as though Mexicanand other Latino immigrants were largely responsible forthe spread of H1N1 onto US soil. It has also attemptedto explain the ways in which some US residents eithercreated, or coped with, the stigmas and stereotypes thatsoon became evident in this charged emotional environ-ment. Our focus group data do not contain direct evi-dence of the involuntary stress responses that developedwhen participants first encountered news reports aboutH1N1. But comments about primary appraisals – theirinitial assessments about whether H1N1 would pose athreat to themselves or to loved ones – suggest thatmost participants did become emotionally aroused byH1N1 news. There were subtle differences in the precisekinds of stress these people mentioned, depending ontheir race and ethnicity. For instance, we found littleevidence that Latino participants first considered thespread of H1N1 to be a significant threat to themselvesor their loved ones. It is possible that respondents fromCity C found it difficult to discern such a threat, giventhe many stressors that people in their community faceon a daily basis. Some Whites, on the other hand, be-came aroused by H1N1 news in a manner that sug-gested fear, disgust and anger. In terms of secondaryappraisals, our focus group participants reported havingmore negative experiences than positive ones – and thistrend was most pronounced among Latinos. While theydid not perceive an immediate or outsized threat fromthe flu, these participants did question whether they hadenough resources to combat it – noting the ubiquity ofairborne viruses and the lack of social support mecha-nisms in the event that one actually becomes ill.In terms of voluntary coping strategies, both Whites
and Hispanics addressed their anxiety over H1N1 news,
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at times, through affirmative problem-solving strategies.People from both groups also made conscious efforts tobalance their desire to express feelings about H1N1 witha perceived need to do so in an even-handed way. Whenfocus group discussions did not focus on flu-related ste-reotypes or stigmas, Latino participants reported muchgreater use of positive-engaged coping strategies thanWhites or Non-Hispanic Blacks. When stereotypes werepart of the conversation, Latinos reported fewer positivestrategies and many more negative-disengaged strategies.This observation can be interpreted, perhaps, by way ofreference to David Williams’ assertion that we humans“tend to think with our hearts” – that the emotionalcontext which surrounds sensitive public conversationshas a powerful impact on whether participants feel em-pathy or antipathy toward people from other socialgroups.e Interestingly, Hispanic participants engaged incognitive restructuring in order to make sense of H1N1(and related stigma) within their own cultural framework.This allowed them to understand the prospect of present-day discrimination in light of their perceptions of histor-ical discrimination at the hands of Whites. This copingstrategy also became manifest when Latinos fused theirsense of natural self-efficacy with strong religious beliefs,embodying the culturally-specific trait known as destino.While our results cannot be broadly generalized, they
do contribute to the scholarly literature in at least threeimportant ways. First, our work corroborates other studiesthat describe the racial and ethnic tensions that some-times lurk beneath the surface of public discourse onH1N1. Second, we demonstrate that two strands ofsocial-psychological theory, cue convergence/associativepriming and a transactional model of stress and coping,can help public health practitioners understand moreclearly that disease outbreaks are social stressors –threatening stimuli that can activate a set of latent fearssome people may hold about members of other racial/ethnic groups. Finally, our work has implications forpublic health and emergency management officials whowant to mitigate the impact of stigmatization duringfuture outbreaks. It is important to note that anti-stigma interventions are not likely to curb this problemcompletely. Since subgroup identification is an importantbasis for sifting one’s way through a sea of complex inter-personal interactions, it is likely that these interactions willalways embody some sense “us” and “them” [31]. Despitethis cautionary note, scholars of stigma – and of H1N1stigma, in particular – do suggest certain fruitful possibil-ities for intervention. First, they maintain that local offi-cials should make people in their communities aware ofthe prospects of stigmatization before the next pandemichits. For example, they can teach their staff membersabout the harm that results from stigmatization; workwith the media to tell their story in a way that does not
single-out one group or location as the “source” of disease;create mechanisms for the rapid portrayal of accurateinformation on disease risk; and ensure that people whofeel stigmatized have a means of expressing their con-cerns [15]. Second, other community and faith-basedorganizations should be reminded to transmit accuratemessages that address people’s concerns about gettingsick; to actively work to mitigate harmful rumors andmisinformation; and to model respectful and compassion-ate behavior when interacting with members of stigmatizedgroups [56]. These guidelines speak to the acknowledgedimportance of building social and cultural-level processesinto any intervention that hopes to address community-wide stigmatization [31,57].Many individual-level interventions have been devel-
oped to combat stigma against certain population sub-groups, including people with AIDS or mental illness. Ingeneral, these interventions have focused on educatingpeople about the impact of stereotypes and stigmas, andon ways in which people can overcome their fears ofsocial out-groups through sustained contact with mem-bers of those groups. Recent reviews of these studiessuggest mixed results, especially in terms of sustainableeffects over the long term [31,37,58]. However, onepromising line of scholarship suggests the possibility ofgreater success with interventions that eschew trad-itional challenges to the “us vs. them” content of stigmaand focus, instead, on enhancing the psychological flexi-bility of all parties involved. According to Masuda et al,psychological flexibility is “the process of engaging withprivate thoughts and feelings without trying to judge,evaluate, alter, fix, down-regulate or change them”. Theseauthors, and others, suggest that a psychologically flexibleperson is less likely to respond to negative thoughts orfeelings with maladaptive coping strategies. Interventionsbased on these principles attempt to undermine the psy-chological impact of stigmatization for all parties involvedby increasing mindfulness, acceptance and perspective-taking – including the development of empathy towardself and others [59-63]. Efforts like these could be an im-portant asset for local health officials who sense the needto develop in-depth, community-wide interventions. Tobe sure, it is difficult to imagine that any local healthdepartment could develop and deploy this sort of anti-stigma intervention without investing a great deal oftime and energy beforehand on education and community-building. But recent studies converge on an interestingfinding that could indicate a hopeful future for such inter-ventions – namely, that people from disadvantaged socialgroups are not the only ones harmed by stigmatization. Forexample, two studies by Masuda and colleagues suggestthat stigmatization directed toward other people is posi-tively related to the stigmatizer’s own psychological distress[40]. And Friedman et al have found that perceptions of
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“reverse discrimination” by White people may have signifi-cant health consequences, including the hastening of in-flammatory processes that could increase the risk ofcardiovascular disease [39]. Armed with this knowledge,public health officials could design campaigns that increasethe motivation of stigmatizing groups to curtail prejudicialstatements by saying, in effect, that “this hurts you, too!”This notion is consistent with one of the basic tenets ofstigma theory, which suggests that “undermining thedistance or distinction between self and others is an im-portant process in stigma reduction interventions” [40,59].It is also consistent with the long-standing observation thatindividuals who stigmatize must be motivated to changetheir ways “not only because it helps those that arestigmatized, but also because it is in one’s own self-interest” [40,64].With respect to traditionally vulnerable population
groups, local practitioners should also take care to under-stand the particular coping resources that group membersmay soon be required to use; resources that may enhancetheir experience of self-control, optimism and social sup-port. This is especially important when considering thecase of Latino immigrants, as a prevailing backdrop ofimmigration-based stigma can hasten the choice of mal-adaptive coping strategies, including self-enforced socialisolation. In addition, perceived discrimination and otherpsychosocial stressors may impact the body’s ability toward off viruses, or to gain full protection from antiviralvaccines [65]. When the impact of stereotypes and stigmasis reasonably low, or when the prevailing social milieu per-mits open and frank discussion, Latinos and members ofother disadvantaged groups can be quite resourceful interms of protecting themselves from the flu, and in gettingthe support they need if they actually become ill. Here, theconcept of destino seems important; suggesting, perhaps,that pandemic planners should direct more effort tosupporting the religious and community organizationsthat can help local residents cultivate this resilient quality.It is important to acknowledge the limitations of our
study. Again, a small sample size means that our conclu-sions cannot be broadly generalized to other people andgroups. And though we argue strongly for the validity ofour results, we must note that they are based upon afraction of the content available in our focus group tran-scripts; simply put, these groups were not designed toelicit discussion about stigmas or stereotypes. With allof this said, our study design was entirely appropriate forthe task at hand. The focus group is an optimal researchmethod for exploring people’s knowledge and experi-ences in their own language [66,67]. This enhances thevalidity of our participants’ comments, since discussionsabout the stigma associated with H1N1 arose organic-ally, without heavy-handed prompts from the moderator.Focus groups are also useful for examining people’s
perspectives on sensitive topics, especially when partici-pants might otherwise be marginalized in the realm ofpublic discussion [66-68]. The conversation that devel-oped freely between moderators and respondents, withinthe safe confines of a small group, allowed for “extensiveprobing, follow-up questions, discussion and the observa-tion of emotional reactions” [67]. For all of these reasons,we feel confident in our choice of research methods andin the results they produced.
ConclusionsOur study has highlighted some of the ways in which flupandemics can be significant sources of individual andsocial stress. Apart from anxiety over personal and familyhealth, and disruptions to jobs and social relations, flu-related stress can also lead to the stigmatization ofmarginalized social groups. Our data show how cer-tain elements of stigmatization – perceived and actual –were present in four Massachusetts communities shortlyafter the onset of the 2009 H1N1 pandemic. And apartfrom simply illustrating these problems, the data alsosuggest ways in which public health and emergencymanagement officials can anticipate and mitigate thenegative impacts of future pandemics. Armed with athorough understanding the racial/ethnic makeup of acommunity – including historical patterns of stress re-sponses and coping behaviors during emergencies –local officials can develop community-wide efforts toprepare for the possibility of stigmatization and, in somecases, to prevent it. They can work with churches andcommunity groups to communicate about the comingthreat in a way that eases social tensions and helpsmembers of traditionally marginalized groups to drawupon their own unique resources in crafting resilient re-sponses to pandemic outbreaks. Recent studies have alsoshown the importance of anti-stigma interventions thatgo beyond simple community-wide education aboutstereotypes and prejudice, and developing these inter-ventions should be a key focus of future research. Inparticular, it seems important to address the underlyingsocial and psychological factors that permit stigma tosurface and persist – hence, the importance of inter-ventions that bolster the psychological flexibility of bothstigmatizers and the stigmatized.Community resilience during pandemics and other
disasters is, in the words of Shoch-Spana, “a complexprocess of adaptation – a collective roll with the punches –that taps into a locality’s social and material strengths”and communal stories [69]. The task of designing pan-demic communication campaigns that work in harmonywith these dynamics can be difficult, however, since it isnot always clear that the residents who are most vulner-able – in terms of health status, socioeconomic position(SEP) and health literacy – can access, understand and act
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upon credible information about the risk of contractingthe disease [22]. For example, people who live in high SEPcommunities may have access to better information aboutpublic health threats than people from low SEP communi-ties. They may also be more likely to comprehend import-ant health communication messages, and to take effectiveaction based on preventive measures that are suggested.With these factors in mind, future research on stigmaprevention might consider various ways in which publichealth practitioners can limit, or even prevent thesecommunication inequalities when pandemics threatentheir communities [22,70].To protect the health of all Americans, public health
officials must do more to combat the historical tendencyto conflate the spread of infectious disease with the in-nate characteristics of foreigners and members of racial/ethnic minority groups. When outbreaks occur, officialsmust hold this tendency in check until scientists are ableto convey a more accurate picture regarding the etiologyof the disease in question [71]. Research on this andother communication problems during pandemic out-breaks will become increasingly important in years tocome, as we strive for greater knowledge about the waysin which social and cultural forces influence the originand propagation of disease. Armed with a better under-standing of social vulnerabilities, we can develop pan-demic planning policies that are more responsive to thebasic human needs that arise during times of crisis [72].
EndnotesaIn the present study, we use the terms Latino and
Hispanic interchangeably.bIn labeling various coping strategies as positive or
negative, we do not mean to pass judgment on any par-ticular strategy or to imply that individual strategies areinvariably good or bad.
cSee Viswanath K, Minsky S, Ramamurthi D, Kontos EZ:Communication under uncertainty: communicationbehaviors of diverse audiences during the H1N1 inci-dence of spring and summer 2009. Unpublished report,Dana-Farber Cancer Institute and Harvard School of PublicHealth, 2009.
dIn the following sections, we use the letter F to referto female focus group participants and the letter M torefer to males. In passages that reproduce dialogic inter-actions between three or more participants, we also usenumbers to distinguish between various male and femalespeakers.
eThese comments come from a keynote address byDavid R. Williams titled Taking Action to the Next Level:Needed Steps to Effectively Tackle Social Disparities inHealth. This address was given on September 27, 2012at the Leading the Way Joint Conference in Milwaukee,WI, co-sponsored by the Medical College of Wisconsin
and the University of Wisconsin School of Medicineand Public Health. For more on Williams’ assertions,see Pettigrew TF, Meertens RW: Subtle and blatantprejudice in Western Europe. Eur J Soc Psychol 1995;25:57-75 and Williams DR, Jackson JS, Brown TN,Tones M, Forman TA, Brown K: Traditional and Con-temporary Prejudice and Urban Whites’ Support forAffirmative Action and Government Help. SocialProblems 1999; 46:503-527.
Additional file
Additional file 1: Focus group script.
Competing interestsThe authors declare they have no competing interests.
Authors’ contributionsMM designed the present study, was the primary focus group analyst, andconceptualized the manuscript. VV is Principal Investigator for the LAMPSproject (see Acknowledgements); he supervised all aspects of the presentstudy and provided scientific direction and guidance. SM is Project Directorfor the LAMPS study; she was responsible for study implementation andsupervised data gathering throughout the focus group process. All authorsreviewed MM’s analyses and contributed to successive drafts of themanuscript. All authors read and approved the final manuscript.
AcknowledgementsThis study was conducted as part of the “Linking Assessment andMeasurement to Performance in PHEP Systems” (LAMPS) project funded bythe Centers for Disease Control and Prevention (CDC) [#1P01TP000307-01].Additional support comes from the NIH/NCI Harvard Education Program inCancer Prevention and Control [R25 CA057713] and the Dana-Farber Farber/Harvard Cancer Center. The authors also acknowledge Divya Ramamurthi,Emily Kontos, Michael Stoto, Elena Savoia and the Mayor’s Health Task Forcein Lawrence, MA for their contributions to our work.
Author details1Department of Medicine, Medical College of Wisconsin, Milwaukee,WI 53226, USA. 2Department of Social and Behavioral Sciences, HarvardSchool of Public Health and Center for Community-Based Research,Dana-Farber Cancer Institute, Boston, MA 02215, USA.
Received: 6 September 2013 Accepted: 25 November 2013Published: 3 December 2013
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doi:10.1186/1471-2458-13-1116Cite this article as: McCauley et al.: The H1N1 pandemic: media frames,stigmatization and coping. BMC Public Health 2013 13:1116.
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